Reasoning GP · Algorithm · 1-page summary
Watery eye (epiphora)
For: adults, children and infants with a watery eye, in hours or OOH. Not for: a painful red eye or reduced vision — that is not simple epiphora (blocks 0–2). Neonates under 28 days with discharge go straight to block 2.
Core rule: a watery eye with pain, photophobia, reduced vision or corneal staining is not simple epiphora until proven otherwise. Watering is often dry eye; persistent one-sided watering, blood-stained tears or a medial canthal mass need a specialist.
0Stop — call 999 now
- Orbital cellulitis (proptosis, restricted eye movement, chemosis, fever) with systemic toxicity, airway or neurological concern → 999 / ED
- Suspected sepsis with any high-risk criterion (NICE NG253), or rapidly progressive visual loss → 999 / ED
- Orbital signs without these → Same-day ED / emergency eye service.
1Triage by pattern — after block 0
| Pattern | Points to |
|---|---|
| Pain, photophobia, ↓ vision, staining | Not simple epiphora → block 2 |
| Bilateral, itch | Allergic conjunctivitis |
| Bilateral, gritty, worse in wind | Dry eye / blepharitis (reflex watering) |
| Unilateral, painless, constant | Drainage obstruction or lid malposition |
| Infant, sticky from birth | Congenital NLD obstruction (CNLDO) |
2Screen — one row is enough
- Acute angle closure (severe pain, vomiting, fixed mid-dilated pupil, corneal haze); corneal ulcer or hypopyon; contact-lens wearer with a red or painful eye → Same-day eye service / ED
- Neonate <28 days with purulent discharge, red eye, marked lid swelling, corneal haze or illness → Same-day paediatrics / ophthalmology. Swab if no delay; specialist-led treatment; parents → sexual health.
- Acute dacryocystitis with fever, illness, spreading cellulitis, visual or orbital signs; infant with a swollen, red, tender medial canthus → Same-day hospital
- Lid will not close (facial palsy) with corneal involvement; suspected gonococcal conjunctivitis (adult, + sexual health) → Same-day ophthalmology
- Persistent unilateral epiphora + blood-stained discharge or firm/fixed medial canthal mass (possible malignancy) → Urgent oculoplastic (local pathway). No routine probing or DCR first.
3Assess — GP minimum
☐ Visual acuity each eye ☐ Pupils if pain or red eye ☐ Lid position, punctum, laxity, lashes ☐ Medial canthus: swelling, discharge on pressure ☐ Fluorescein if pain, photophobia, contact lenses or visual change ☐ Proptosis, motility, temperature if orbital disease possible
Ask: one or both eyes, constant or intermittent, itch, grit, eye drops (prostaglandin analogues, timolol), trauma, nasal surgery. Not GP tests: syringing, probing, Schirmer, allergy testing.
4Classify — only if the screen is negative
- Dry eye / blepharitis — gritty, burning, worse in wind or with screens → lid care, lubricants.
- Allergic conjunctivitis — bilateral, itch is the hallmark, seasonal or perennial → block 5.
- Infective conjunctivitis — viral: watery, follicles, preauricular node; bacterial: mucopurulent → supportive care.
- CNLDO — infant, watery sticky eye, no inflammation; most resolve in infancy → massage and reassure.
- Acquired NLD obstruction or lid malposition — older adult, one-sided overflow, white eye; ectropion, entropion, trichiasis → block 6.
- Uncertain — say so → optometry / ophthalmology.
5Treat today — doses: NICE/SPC, BNF, local formulary
- Dry eye / blepharitis: warm compress 10 min then lid hygiene twice daily for 4–6 weeks; preservative-free lubricants if used often.
- Allergic: avoidance, cold compresses; sodium cromoglicate 2% (local first choice) or olopatadine 1 drop BD (max 4 months; avoid in pregnancy and breastfeeding); oral antihistamine for rhinitis.
- Conjunctivitis: no routine antibiotics; consider a topical one only if severe, marked purulence, significant discomfort, immunocompromise or not improving. No school exclusion; hand hygiene.
- Acute dacryocystitis, well adult: oral antibiotic per local guideline (local: co-amoxiclav 625 mg TDS for 7 days), analgesia, warm compresses. CNLDO: show gentle sac massage; lid cleaning.
6Refer
- Urgent (local pathway) oculoplastics: persistent unilateral NLD obstruction, recurrent dacryocystitis, lid malposition with corneal exposure, trichiasis with staining.
- CNLDO persistent and troublesome → paediatric ophthalmology, usually around 12 months; earlier if dacryocystitis, sac swelling, atypical or corneal signs.
- Routine optometry / ophthalmology: troublesome epiphora without red flags; dry eye or blepharitis not responding; lid malposition without exposure.
- Severe vernal / atopic keratoconjunctivitis → ophthalmology. Sjögren's → ANA, anti-Ro/La + rheumatology.
7Never reassure by
- "Just a watery eye" when there is pain, photophobia, reduced vision or staining.
- Calling a contact-lens wearer's red eye conjunctivitis.
- Topical antibiotics alone for a sticky red eye in a neonate.
- Labelling blood-stained tears or a canthal mass as recurrent dacryocystitis.
- A topical steroid for an undifferentiated red eye.
- Massaging, probing or syringing an acutely inflamed sac.
8Safety-net — say it, then document it
999 “Call 999 or go to A&E if the eye bulges or will not move, you have a fever and feel very unwell, or your sight is getting worse quickly.”
Same day “Contact us or the emergency eye service today for eye pain, light sensitivity, any change in vision, a red or painful eye with contact lenses (take them out), or a swollen, red, tender lump at the inner corner. A newborn with a sticky red eye is seen today.”
Review: viral conjunctivitis not better at 2 weeks or worse; watering not improving on lid care and lubricants → block 6.
✓Safe to leave primary care only if — all five, documented
No block 0–2 row applies
Visual acuity recorded; fluorescein if pain or photophobia
Medial canthus checked: no mass or blood-stained discharge
Cause named, or uncertainty stated with referral
Safety-net given; review or referral date set
Summary of the full Reasoning GP watery eye algorithm, which holds the detail, examination, treatment ladders and evidence. Sources: NICE NG195, NG253, NG12 (updated April 2026), HTG68, TA369; local antimicrobial guideline and local formulary; MHRA; BASHH; College of Optometrists; UKHSA. Clinical reference — local ophthalmology, paediatric and antimicrobial pathways take precedence; check doses: NICE/SPC, BNF.